Context The increased incidence of thyroid cancer globally over the past several decades is principally attributed to small, indolent papillary thyroid cancers. A possible concomitant increase in thyroid cancer-specific mortality remains debated. Objective The changes in thyroid cancer incidence and incidence-based mortality were assessed using a large population-based cohort over an 18-year period. Design & Patients A retrospective analysis of all thyroid cancers reported in the California Cancer Registry was performed (2000–2017). Age-adjusted incidence and incidence-based mortality rates were analyzed using a log-linear model to estimate annual percent change. Results We identified 69 684 individuals (76% female, median age 50 years) diagnosed with thyroid cancer. The incidence of thyroid cancer increased across all histological subtypes (papillary, follicular, medullary, and anaplastic) and all tumor sizes. The incidence increased from 6.43 to 11.13 per 100 000 person-years (average increase 4% per year; P < 0.001) over the study period. Thyroid cancer-specific mortality rates increased on average by 1.7% per year (P < 0.001). The increased mortality rates were greater in men (2.7% per year, P < 0.001) and patients with larger tumors (2-4 cm) (3.4% per year, P < 0.05). Conclusions Data from this statewide registry demonstrate that the incidence of thyroid cancer is increasing, and that this phenomenon is not restricted to small papillary thyroid cancers. Rising incidence in thyroid cancers of all sizes with concurrent increase of incidence-based mortality in men and those with larger tumors suggest a true increase in clinically significant disease.

Normocalcaemic primary hyperparathyroidism is a condition that can present with intermittent hypercalcemia or may evolve into hypercalcemic primary hyperparathyroidism. This milder biochemical entity remains incompletely understood because of a lack of long-term health outcomes regarding both medical and surgical approaches to its management. Medical therapies have shown some efficacy. A limited number of studies have found that bisphosphonates increase bone mineral density, and cal

tutional Review Board deemed this study exempt from review because it was classified as a quality improvement study. The study followed the SQUIRE reporting guideline.Results | Daily PT, INR, and PTT tests decreased from a mean 463.8 tests per day before to 329.0 per day after the BPA (-29.1%; P < .001). The reduction after the BPA was -31.4%, assuming that temporal trends (slopes) before and after the BPA were the same, and -26.0% when trends before and after the BPA were fitted separately (P < .001 for each). The trend for testing (ie, the slope) was slightly higher after the BPA (15 more tests per 100 days vs 10 more tests per 100 days before BPA; difference, 5 [95% CI, 0-10] tests per 100 days; P = .07). However, this trend was associated with less than a 10% reduction in the estimated effect size during the 6-month follow-up period (Figure).

Context Primary hyperparathyroidism (PHPT), a leading cause of hypercalcemia and secondary osteoporosis, is underdiagnosed. Objective To establish a foundation for an electronic medical record-based intervention that would prompt serum parathyroid hormone (PTH) assessment in patients with persistent hypercalcemia and identify care gaps in their management. Design Retrospective cohort study. Setting Tertiary academic health system. Patients Outpatients with persistent hypercalcemia, who were then categorized as having classic or normohormonal PHPT. Main Outcome Measures The frequencies of serum parathyroid hormone (PTH) measurement in patients with persistent hypercalcemia, and their subsequent workup with bone mineral density (BMD) assessment, and ultimately, medical therapy or parathyroidectomy. Results Among 3151 patients with persistent hypercalcemia, 1526 (48%) had PTH measured, from whom 1377 (90%) were confirmed to have classic (49%) or normohormonal (41%) primary hyperparathyroidism (PHPT). PTH was measured in 65% of hypercalcemic patients with osteopenia or osteoporosis (p&lt;0.001). Upon median two year follow-up, bone density was assessed in 275 (20%) patients with either variant of PHPT (p=0.003). Of women ≥ 50 years of age with classic PHPT, 95 (19%) underwent BMD assessment. Of patients with classic or normohormonal PHPT, 919 patients (67%) met consensus criteria for surgical intervention, though only 143 (15%) underwent parathyroidectomy. Conclusions Within a large academic health system, over half of patients with confirmed hypercalcemia were not assessed for PHPT, including many patients with preexisting bone disease. Care gaps in BMD assessment and medical or surgical therapy represent opportunities to avoid skeletal and other complications of PHPT.

Background: Primary hyperparathyroidism (PHPT) is the leading cause of hypercalcemia in the outpatient population and is associated with nephrolithiasis, osteoporosis, and further end-organ effects. When indicated, parathyroidectomy is an effective intervention. The aim of this study was to assess the prevalence of patients with hypercalcemia resulting from undiagnosed PHPT within a large, urban, academic healthcare system. Methods: The study population comprised all patients within UCLA Health. The electronic medical record was queried between 01/01/2016-12/31/2018 to include patients with at least two elevated serum total calcium concentrations (&gt;10.4 mg/dL) within a six-month period in the outpatient setting. Causes of secondary and tertiary PHPT were excluded. In concordance with the PHPT diagnostic criteria outlined by the Fourth International Workshop, we evaluated the proportion of patients with hypercalcemia who were further assessed with a serum intact parathyroid hormone (iPTH) test. The study identified cases of PHPT as defined by confirmed elevated serum total calcium concentrations and elevated or inappropriately normal iPTH concentrations. Results: There were 7102 patients with a single elevated serum total calcium result who never received a repeat assessment within the study period. Although there were 5617 patients with confirmed hypercalcemia, only 2773 (51%) had an iPTH level assessed within six months of the repeated calcium measurement. Of those who underwent iPTH testing, 1931 (69%) were biochemically confirmed to have classic (34.2%) or normohormonal (35.4%) PHPT; the remaining 31% had an appropriately suppressed iPTH concentration relative to the hypercalcemia. Conclusions: In a large, academic, tertiary healthcare center, over half of the ambulatory patients with confirmed hypercalcemia did not receive further work-up to assess for possible PHPT. Efforts to improve diagnosis of PHPT and expand curative treatment have the potential to decrease the prevalence of nephrolithiasis, bone loss, and further end-organ effects associated with the disease.